What are the major arteries I should be aware of during surgery?

Major Arteries to Know During Surgery

The most important arteries to be aware of during surgery include the aorta and its major branches, including the femoral, iliac, carotid, and renal arteries, as these vessels are critical for maintaining adequate perfusion and preventing life-threatening complications during surgical procedures.

Aorta and Its Major Branches

Thoracic Aorta

• Ascending aorta: Primary site for arterial cannulation in cardiac surgery
• Aortic arch: Gives rise to three major branches:
  • Brachiocephalic (innominate) artery
  • Left common carotid artery
  • Left subclavian artery
• Descending thoracic aorta: Continues from the arch to the diaphragm

Abdominal Aorta

• Celiac trunk: Supplies the liver, stomach, and spleen
• Superior mesenteric artery: Supplies most of the small intestine and proximal colon
• Renal arteries: Critical for kidney perfusion
• Inferior mesenteric artery: Supplies the distal colon and rectum
• Common iliac arteries: Terminal branches of the abdominal aorta

Critical Arterial Considerations by Surgical Approach

Peripheral Cannulation Sites

For minimally invasive cardiac surgery or emergency access, key arteries include:

1. Femoral artery:

   • Primary choice for rapid cannulation in emergencies 1
   • Requires pre-assessment with CT angiography to evaluate for atherosclerosis, tortuosity, or dissection 1
   • Common femoral artery diameter should be measured to ensure adequate size for cannulation (typically requiring 21F-23F cannulas) 1

2. Axillary/Subclavian artery:

   • Increasingly used for cannulation, especially in aortic dissection 1
   • Advantages include antegrade flow in arch vessels and typically less atherosclerosis 1
   • Rich collateral vessels to distal arm provide protection against ischemia 1

3. Innominate artery:

   • Can be used for both cardiopulmonary bypass and antegrade selective cerebral perfusion 2
   • Associated with superior neurological outcomes compared to femoral cannulation 2

Abdominal Surgery Considerations

• Aorta: Evaluate for aneurysms, calcification, and atherosclerotic disease
• Renal arteries: Critical to identify to prevent inadvertent injury during abdominal procedures
• Mesenteric vessels: Damage can lead to bowel ischemia and significant morbidity

Vascular Pathology Awareness

Atherosclerotic Disease

• Common femoral artery bifurcation: Frequent site of atherosclerotic disease
• Aortoiliac segment: Evaluate for calcification and stenosis before cannulation 1
• Carotid bifurcation: High-risk area for atherosclerotic plaque

Anatomic Variations

• Be aware of potential variations:
  • Aberrant right subclavian artery
  • Accessory renal arteries (present in approximately 25% of individuals)
  • Patent ductus arteriosus
  • Persistent left superior vena cava 1

Preoperative Assessment of Arterial Anatomy

CT angiography provides critical information for surgical planning:

• Vessel diameter measurements
• Degree and location of atheroma (hard vs. soft plaque)
• Vessel tortuosity
• Aneurysmal disease
• Calcification patterns 1

Intraoperative Monitoring and Protection

1. Monitor for arterial injury signs:

   • Unexpected bleeding
   • Hematoma formation
   • Hemodynamic instability
   • Distal ischemia

2. Protection strategies:

   • Use epiaortic scanning to identify atherosclerotic disease before cannulation or clamping 1
   • Consider distal perfusion strategies when cannulating femoral arteries 1
   • Monitor lower extremity perfusion with near-infrared oximetry when using peripheral cannulation 1

Complications to Watch For

1. Aortic dissection: Can occur during cannulation (0.06-0.23% of aortic cannulations) 1

   • Lower systolic pressure below 100 mmHg before cannulation
   • Watch for sudden hemodynamic instability or unexplained bleeding

2. Embolic events: From dislodgement of atheromatous debris

   • Use specialized cannulas that minimize jet effects
   • Consider alternative cannulation sites in heavily calcified vessels 1

3. Limb ischemia: During peripheral cannulation

   • Consider placement of a small cannula in the distal superficial femoral artery if significant difference in perfusion is detected 1

By maintaining awareness of these major arterial structures, their common pathologies, and appropriate management strategies, you can help minimize vascular complications and contribute to safer surgical outcomes.